Community Antibiotic Policy February 2020, Issue 7

1 Community Antibiotic Policy February 2020, Issue 1 Antibiotic GUIDANCE FOR SHROPSHIRE & POWYS PRIMARY CARE This document replaces Antibiotics for Adults in Shropshire and Powys primary Care, Issue Comments/suggested changes for consideration welcome. Send to Using antibiotics is a not a subject where every answer can be pre-defined. These guidelines describe first steps in common situations and are not comprehensive or applicable to patients with two infections. Section 1 are empirical guidelines based on NICE/PHE Antimicrobial prescribing guidelines and Management and Treatment of Common Infections from PHE (references and grading of guidance recommendations are available at Guidance for primary care - Publications - ). Empirical management will not deal with unexpected resistance, which means failure and changing antibiotics. If the situation you meet is not covered, microbiologists will be pleased to help.

2 Note the guidance deliberately does NOT generally cover any other aspects of diagnosis (see laboratory handbook), vaccination or immunisation (See DH guidelines ) or non- Antibiotic treatment of infection. Community Antibiotic Policy February 2020, Issue 2 CONTENTS Click on table of contents to go to relevant page .. 5 Advice .. 5 Principles of Treatment .. 6 MENINGITIS .. 7 UPPER RESPIRATORY TRACT INFECTIONS: .. 8 Influenza .. 8 Coronavirus (COVID-19) .. 8 Acute Otitis Externa .. 9 Otitis media .. 9 Scarlet Fever .. 9 Pharyngitis/ sore throat/ tonsillitis .. 10 Acute sinusitis .. 10 LOWER RESPIRATORY TRACT INFECTIONS .. 11 Acute cough, bronchitis .. 11 Exacerbation of COPD .. 11 Exacerbation of Bronchiectasis .. 12 Community -acquired pneumonia .. 12 URINARY TRACT INFECTIONS .. 13 Lower UTI .. 13 Urinary 13 Acute pyelonephritis .. 14 UTI in pregnancy.

3 14 Children .. 14 Recurrent UTI women .. 14 Acute Prostatitis .. 14 GASTRO-INTESTINAL TRACT INFECTIONS .. 15 Infectious diarrhoea .. 15 Traveller s diarrhoea .. 15 Threadworms .. 15 Oral 15 Clostridium difficile .. 16 Community Antibiotic Policy February 2020, Issue 3 Diverticulitis .. 16 Eradication of Helicobacter pylori .. 16 GENITAL TRACT INFECTIONS .. 17 STI screening .. 17 Chlamydia trachomatis/ urethritis .. 17 Trichomonas .. 17 Pelvic Inflammatory Disease .. 17 Gonorrhoea .. 18 Genital Herpes .. 18 Vaginal candida .. 18 Bacterial vaginosis .. 18 Epididymitis .. 18 SKIN & SOFT TISSUE INFECTIONS .. 19 PVL .. 19 Eczema .. 19 Impetigo .. 19 Cellulitis .. 19 Foot and Leg Ulcers .. 20 Animal Bite .. 20 Human Bite .. 20 Acne .. 20 Mastitis .. 20 Dermatophyte infection of the fingernail or toenail .. 21 Dermatophyte infection of the skin .. 21 Varicella zoster/ Chicken pox.

4 21 Cold sores .. 21 Scabies and Head Lice .. 22 Tick 22 EYE INFECTIONS .. 23 Conjunctivitis .. 23 Blepharitis .. 23 DENTAL INFECTIONS .. 24 Toothache .. 24 Mucosal ulceration and inflammation .. 24 Acute necrotising ulcerative gingivitis .. 24 Community Antibiotic Policy February 2020, Issue 4 Pericoronitis .. 24 Dental abscess .. 25 2. SPECIFIC ANTIMICROBIAL AGENTS .. 26 3. SPECIFIC 27 Clostridium difficile .. 27 MRSA .. 28 ESBL (Extended Spectrum B lactamase) producing coliforms .. 29 4. Antibiotic ASSAYS FOR PRIMARY CARE .. 30 Teicoplanin assays .. 30 Tobramycin levels .. 30 Itraconazole and voriconazole levels .. 31 5. Community INTRAVENOUS Antibiotic PRESCRIBING .. 32 6. PROPHYLAXIS .. 35 Bacterial endocarditis .. 35 Prosthetic Joints .. 36 Prophylaxis post-splenectomy .. 36 7. Antibiotic RESISTANCE RATES .. 37 8. REFERENCES .. 37 Community Antibiotic Policy February 2020, Issue 5 1.

5 EMPIRICAL USE guidelines . to provide a simple, effective, economical empirical approach to the treatment of common infections to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance in the Community Advice Can be obtained, if infection is severe, from the following by e-mail or telephone: Clinical Bacteriology Results (Phone) 01743 261000 ext 1161/1167 Serology, Molecular & Virology Results (Phone) 01743 261000 ext 3205/1161 Clinical Enquiries Dr Michael Brian - Dr Stephanie Damoa-Siakwan Dr Graham Harvey Yasar Hussain Dr Moira Kaye Dr Patricia O Neill Unless otherwise stated, these guidelines are intended for adults only. Different antibiotics doses are, and different choices may be, needed for children. However, bacterial infection is commoner as a cause of sore throat, otitis media and sinusitis in children so Antibiotic guidance in these sections considers children.

6 Not all conditions are covered. HIV therapy and Tuberculosis therapy are dealt with by specialist physicians. Community Antibiotic Policy February 2020, Issue 6 Principles of Treatment This guidance is based on the best available evidence but its application must be modified by professional judgement. It is important to initiate antibiotics as soon as possible in severe infection Prescribe an Antibiotic only when there is likely to be a clear clinical benefit. Do not use antibiotics for acute sore throat, colds, acute cough or sinusitis. Delayed Antibiotic prescription is an option. Do not treat organisms in leg ulcers unless there is a 2cm erythematous zone suggesting cellulitis (unless attempting MRSA clearance). Avoid prescribing over the telephone except in exceptional cases. Use simple generic antibiotics first whenever possible. Avoid broad-spectrum antibiotics when narrow spectrum antibiotics remain effective, as broad-spectrum antibiotics increase the risk of Clostridium difficile, MRSA and resistant UTIs.

7 All antibiotics have the potential to induce Clostridium difficile associated diarrhoea. Carbapenems, cephalosporins, quinolones and clindamycin are considered to be high-risk while metronidazole, flucloxacillin, doxycyline, trimethoprim and amoxicillin are lower risk agents. A dose and duration of treatment is suggested for adults. Give short courses of antibiotics where possible. Five days is normally adequate unless otherwise stated and 3-day courses are satisfactory for cystitis. Always review by 7 days if you plan to continue antibiotics. Try to avoid giving a series of antibiotics for one infection. Another organism or pharmacological factors such as dose, absorption, and penetration to the site of infection, may be responsible for treatment failure. Always enquire about the nature of any reported allergy and previous reaction; symptoms such as nausea and diarrhoea are not features of true allergy.

8 Less than 10% of individuals who are penicillin allergic are allergic to cephalosporins or carbapenems. These agents should not be given to those with a history of facial/oral swelling, difficulty breathing or urticarial rash with penicillins. Use higher doses in patients weighing >70Kg and certainly if the patient weighs >100Kg, penicillins are particularly safe to use at high dose. When using flucloxacillin use 1G qds for severe Staph aureus infection up to 70Kg, g qds from 70-100Kg and 2G qds >100Kg. Avoid widespread use of topical antibiotics (especially gentamicin, fucidin and mupirocin) In pregnancy AVOID tetracyclines, aminoglycosides, ciprofloxacin, high dose metronidazole (2g). Take specimens to inform treatment. Short-term use of trimethoprim (theoretical risk in first trimester in patients with poor diet, or taking another folate antagonist) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.

9 Where a best guess therapy has failed or special circumstances exist, microbiological samples are essential. This guidance should not be used in isolation; it should be supported with patient information about back-up/delayed antibiotics, infection severity, usual duration and clinical staff education. Materials are available on the RCGP TARGET website. Community Antibiotic Policy February 2020, Issue 7 ILLNESS COMMENTS TREATMENT ADULT DOSE (unless stated) DURATION MENINGITIS Suspected meningococcal disease PHE -Meningococcal Meningitis in under 16s NICE Meningitis - NICE CKS Transfer all patients to hospital immediately. If time, administer benzylpenicillin or ceftriaxone/cefotaxime stat prior to admission, unless history of difficulty breathing, collapse, loss of consciousness or urticarial rash with these agents. Ideally IV but IM if a vein cannot be found.

10 Iv or im Benzylpenicillin Iv or im Ceftriaxone or Cefotaxime Adults and children 10 yr and over: 1200 mg Children 1 - 9 yr: 600 mg Children <1 yr: 300 mg Adults, >12y 1G, Children <12y: 50mg/Kg, Prevention of secondary case of meningitis: Only prescribe following advice from Public Health Doctor: 9 am 5 pm: 0344 225 3560 opt2 then opt2 Out of hours: Contact on-call Public Health Doctor via RSH switchboard 01743 261000 Community Antibiotic Policy February 2020, Issue 8 UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed Antibiotic prescriptions. Influenza Treatment and prophylaxis: PHE Seasonal influenza Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals are not recommended. Treat at risk patients with antivirals: - when influenza is circulating in the Community , within 48 hours of onset of symptoms - during localised outbreaks in long term and residential nursing homes, if there is a high level of certainty that the causative agent is influenza (see CCG guideline on prescribing antivirals in this situation).